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Concussion...the hot topic: return to play rules following a sports-related head injury



Concussion is a functional rather than a structural brain injury.


Current recommendations are that the management of concussions should be individualized based on an athlete’s symptoms and recovery rather than on classification of severity.


Features of sport-related concussion





Visual disturbances

Photophobia (extreme sensitivity to light)

Phonophobia (abnormal fear of sound)

Loss of consciousness



Loss of balance/poor coordination

Decreased playing ability




Emotional lability



Inappropriate emotions



Slowed reaction times

Difficulty concentrating

Difficulty remembering


Feeling in a fog

Feeling dazed




Trouble falling asleep

Sleeping more than usual

Sleeping less than usual


If any of these are exhibited following an injury, concussion should be suspected and appropriate management initiated. In younger children, signs and symptoms can be subtle, such as stomach pain or upset and behavioural changes rather than headache or cognitive symptoms. There is evidence to suggest there are age-related differences in recovery following concussion, with younger children taking longer to recover.


An athlete who has sustained a head injury during sport should be removed from play immediately and not allowed to return to play that game. The athlete should be closely monitored for any signs of deterioration, and should not be left alone (for the first 24 to 48h). All athletes sustaining a head injury should be evaluated by a physician as soon as possible.


A responsible adult, ideally a parent, should monitor the child or youth for worsening symptoms (eg, severe headache, persistent vomiting, seizure activity), and check through the night for signs of deterioration (eg, abnormal breathing, seizures). Because sleep is necessary for recovery, however, a child or youth with concussion should not be awakened during the night. If there are any signs of deterioration the child or youth should be re-evaluated immediately in an emergency department.


The most important aspect of concussion management is rest. This includes both physical and cognitive rest. The injured child or youth should not play sports, exercise or participate in recreational activities such as bike riding, or wrestling with friends or siblings. Cognitive rest includes limiting activities that require mental concentration, such as reading, texting, watching television, computer work and electronic games.


Concussed athletes may even need to miss school or have modifications made to their learning program while symptomatic, to avoid worsening symptoms due to the mental effort required to perform school work. If an absence from school is necessary, children and adolescents should then return gradually (eg, attending half-days) as symptoms improve. If symptoms do not worsen or recur, they may return to school full-time. If a prolonged absence from school (more than a couple of weeks) is necessary due to persistent symptoms, referral to a specialist with expertise in concussion may be required.


In certain circumstances, pharmacological therapy may be used to manage specific prolonged symptoms, such as sleep disturbances, depression or anxiety. However, athletes should not be taking any medications that may mask signs/symptoms of concussion when returning to play.


An athlete with a concussive injury should not be allowed to return to activity until all signs and symptoms have resolved and he/she has been cleared to do so by a physician.


Once children and adolescents have been symptom-free for several days, they should then follow a medically supervised stepwise exertion protocol.


Each step should take a minimum of 24 h. As long as symptoms do not return, athletes may progress to the next step. If symptoms recur, athletes should rest for 24 to 48 h before trying to progress again, and starting with the last level where they were asymptomatic.


Graduated return to play protocol (after a sport-related concussion) 


Rehabilitation stage 1No activity - Complete physical and cognitive rest: Stage objective - Recovery 


Rehabilitation stage 2Light aerobic exercise - Walking, swimming or stationary cycling, keeping intensity at <70% MPHR (maximum predicted heart rate); no resistance training: Stage objective - Increase HR


Rehabilitation stage 3Sport-specific exercise - Skating drills in hockey, running drills in soccer; no head impact: Stage objective - Add movement


Rehabilitation stage 4Non-contact training drills - Progression to more complex training drills, (eg, passing drills in football and ice hockey); may start progressive resistance training: Stage objective - Exercise, coordination, and cognitive load


Rehabilitation stage 5Full contact practiceAfter medical clearance, participate in normal training activities: Stage objective - Restore confidence and assess functional skills by coaching staff


Rehabilitation stage 6Return to play - Normal game play



Canadian Pediatric Society



Here are some helpful website links on this common topic:


HEADS UP to youth sports: The Center for Disease Control and Prevention 


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